Saratoga, CA · Santa Clara County
Workers Compensation Declaration
Permit applicants use this form to declare their workers’ compensation coverage or certify that they will not employ anyone subject to coverage requirements.
What this form is
The Workers Compensation Declaration is a statement that every permit applicant must file, according to the form. It asks for the project address and permit number, a selection among three workers’ compensation declarations, contractor and business details, and the signer’s signature and date; insured applicants also provide their carrier and policy number unless the permit is $100 or less.
Who needs it
Anyone applying for a permit must file this declaration and select one of its three workers’ compensation statements.
How to submit it
File the declaration with your permit application through the Community Development Department, 13777 Fruitvale Avenue, Saratoga, CA 95070. The form also lists www.saratoga.ca.us/cdd and 408.868.1240.
About notarization
This declaration is signed and dated without a notary; it includes an affirmation under penalty of perjury, but no notarized attachment or separate sworn step.
How to submit this form
- 1
Download the Declaration
Download the Workers Compensation Declaration PDF.
- 2
Complete the Form
Enter the project and permit details, select one declaration, and provide the requested business and contractor information.
- 3
Check Your Information
If you select the workers’ compensation insurance declaration, provide your carrier and policy number unless the permit is $100 or less.
- 4
Sign and File
Sign and date the declaration, then file it with your permit application through the Community Development Department.
Frequently asked questions
- Who must file the Workers Compensation Declaration?
- The form says every applicant for a permit must file a statement regarding workers’ compensation coverage.
- What information does the declaration request?
- It requests the project address, permit number, one selected declaration, contractor and business information, and a signature and date. Insured applicants may need to provide carrier and policy number.
- Do I need a notary for the Workers Compensation Declaration?
- No. The signer signs and dates the declaration without a notary. It contains an affirmation under penalty of perjury, but no notarized attachment or separate sworn step.
- How do I submit the Workers Compensation Declaration?
- File it with your permit application through the Community Development Department at 13777 Fruitvale Avenue, Saratoga, CA 95070.